FAQ Category: Lumbar Spine

Lumbosacral radicular syndrome (LRS) is a common cause of low back, buttock, and leg pain. The disc protrudes from its space and puts pressure on the closest nerve root. Sometimes chemicals released by the damaged disc irritate the nerve root, too. Either way, the result is pain, numbness, and tingling. If the problem persists, muscle weakness and atrophy can also occur.

When conservative care doesn’t work, then surgery to remove the disc called a discectomy may be needed. The last 10 years has seen a trend away from discectomy combined with a laminectomy (removal of bone) and fusion. Now a simple discectomy is done to avoid further problems from the spinal surgery.

Studies report there’s still a 10 to 40 per cent rate of complications after a simple discectomy. Failure to correct the problem could be caused by a variety of factors. Some are patient-caused, while others are surgeon-derived. Work and legal status and psychologic state of the patient, and surgical skill and technique on the part of the surgeon are part of this equation.

Your son’s surgeon has probably advised him to have a simple discectomy based on the results of X-rays and MRIs. The doctor also takes into consideration the person’s general health, overall attitude, and work situation. His chances of getting back to work and daily life are better with the less invasive surgery.

According to a recent study from the Netherlands, most low back pain (LBP) patients return to work (RTW) before their symptoms are completely gone. Going back to work does not cause more harm than staying home on sick leave.

People who have had a previous episode of back pain RTW earlier compared to patients having their first bout of LBP. This may be because they have learned how to handle it.

It is possible that going back to work actually helps patients recover even more. More research is needed to prove this. For now it’s clear that RTW is linked most directly to function. In other words, RTW occurs when the patient can perform the movements and tasks required by the job.

If your job is physically demanding, then you may want to seek the advice of a physical therapist trained to make work assessments. The therapist will test you to see how closely your strength, endurance, and skill match those required by your job. Sometimes an intermediary rehab program is needed to transition patients back to work safely.

Many people with varying backgrounds and training are offering Pilates exercise programs. In other words, not all Pilates programs are equal. The program may need to be specifically designed for anyone with a back injury or other problem. Early studies show that a supervised Pilates program works well to reduce pain and improve function for low back pain patients.

A physical therapist (PT) will assess your posture and breath control. These two factors are key to correctly performing Pilates exercises. The PT will also check your muscle strength, flexibility, and endurance. All of this information is needed to prescribe a Pilates program that will help restore motor control needed for spinal stability.

Once you get started in a Pilates program that is safe and effective, then you can transition to a class for the general public. Knowing what works best for your situation will help you to adapt Pilates exercises provided by any other trained teacher.

You may have had an operation called a microdiscectomy. With microdiscectomy, the surgeon carefully removes just the herniated or damaged portion of the disc. Any healthy, viable tissue in good condition is left intact.

If you’ve had a microdiscectomy, it’s possible to reherniate the remaining disc material. A second operation called revision microdiscectomy may be needed. However, you may have a disc herniation at a different level either above or below the first herniation. This could also cause the same or similar symptoms to occur.

Only with a radical discectomy (complete removal of the disc) are you free of the worry of another herniation at the same location. Even with a radical discectomy, disc herniation at a different spinal level can occur.

It’s best to have your surgeon review your case and find out what’s going on. You may be able to treat your new symptoms with specific exercises prescribed by a physical therapist and avoid having another operation.

As you described, microdiscectomy only removes fragments or portions of the damaged disc. Recurrent herniation of the remaining disc is still possible. In fact, this happens in about 10 percent of the patients who have this surgery.

The return of your sciatica could be from disc reherniation at the same level. Or it could be a new disc herniation at a slightly different level. Scar tissue called fibrosis is also a possible cause of your symptoms. Arthritis can actually be one other reason for your new symptoms.

None of these problems can be diagnosed on the basis of just your symptoms. Further testing is advised. See your surgeon and report your symptoms. Early diagnosis and treatment may result in better long-term results.

Many people report these kind of pain experiences. It’s possible to avoid thinking about the pain during the day by keeping busy. Distraction or pulling the mind away from the dreaded pain works well. This techniques doesn’t work when trying to go to sleep.

Research even shows that paying attention to the painful or affected part of the body produces feelings of dread just waiting for the pain to start. Pain may start just to get over waiting for it.

There is a relaxation or distraction method for daytime or nighttime use that may help you. It’s called physiologic quieting®. Using the mind and your thoughts, you can quiet the nervous system in charge of pain pathways.

By quieting your thoughts you can slow your heart rate and lower your blood pressure. In this way you can enter a state of altered relaxation and then drift off to sleep. If you can’t sleep or you wake up from a sound sleep and can’t go back to sleep, you can repeat the steps of physiologic quieting.

A patient care kit for home use is available from Phoenix Publishing at www.phoenixpub.com or by calling 1-800-549-8371.

We are living in the age of women’s health studies. Large groups of women are enrolled in several long-term studies around the world. For example, the Nurses Health Study I sponsored by the National Institutes of Health was started in 1976. The main reason for the study was to see if there were any long-term problems from using oral contraceptives. Since that time, the data has been analyzed for many other purposes.

A second study (Nurses Health Study II) was started in 1986 and expanded from the original research. Other large studies of men and women together also provide data on both genders that can be analyzed separately. For example, the Framingham Study has been used to understand heart disease.

Data from the Monitoring Project on Risk Factors for Chronic Diseases (MORGEN) in the Netherlands has been used to compare reproductive and hormonal factors with musculoskeletal pain in women. The focus was on chronic back and/or arm pain.

Researchers found that a history of past pregnancy was associated with an increased risk of musculoskeletal pain. Likewise early age (less than 20 years) at the time of the first pregnancy was linked with chronic low back pain (LBP) later.

Studies show about 10 per cent of women with chronic LBP report it started during pregnancy. The exact biologic mechanism is unknown. It’s likely that there are many factors, not just one. Stress on joints and ligaments, fatigue, and hormones designed to relax the soft tissues may all have a role.

It’s also possible the combination of hormonal factors and the work load of caring for young children added together increase the risk of future episodes of LBP.

Many experts do think there’s a direct link between oral contraceptive use and low back pain (LBP). Actual evidence to support this is scarce. There is some data to show estrogen use during menopause can increase the risk of LBP.

A recent study of 11,428 Dutch women may shed some light on this subject. Information was collected by survey including questions about pregnancy history, age at first birth, number of children, and use of oral contraceptives (OC) or other hormones. Questions were also asked about menstrual cycle and regularity at the start of the girls’ first period.

They found that duration of OC use was linked with increased risk of LBP. The longer a woman was on OCs, the greater the risk of LBP. OC use appears to increase ligamentous laxity in the pelvis resulting in LBP.

There’s no way to predict who might have back pain from taking OCs. Talk with your doctor about your concerns. With the right pill and careful monitoring, you may be able to use OCs without any increase in your back pain. Or your physician may suggest a better birth control method for you.

There are two basic ways to do a spinal fusion: the anterior or posterior approach. Anterior means the surgeon goes through the patient’s abdomen to reach the spine. Posterior refers to entry from behind the spine. Most often the posterior approach is really posterolateral (PL). PL indicates the entry is at an angle from the back and side. This method avoids pulling the nerve root out of the way.

PLIF stands for posterior lumbar interbody fusion (PLIF). The disc is removed and replaced with a titanium cage. PLIF helps reduce back pain but can result in nerve pain from damage when the nerve is retracted. PLIF does restore the natural disc height which takes pressure off the nerve roots as they leave the spinal canal.

Surgeons often choose PLIF because there is less blood loss and a shorter operative time. And without a bone graft for the fusion there are no donor site problems.

Your decision to return to sports may depend on your symptoms and current level of function. Studies show that younger males have a faster recovery time and return to work sooner after an episode of low back pain. Sports participation seems to be linked with improved function and quality of life (QOL).

Talk to your doctor if you have doubts or concerns about returning to recreational activities safely. Physical activity has been shown to have a positive effect on overall health-related QOL. Unless there is a specific danger, you’re likely to be given the green light to go ahead.

It may be best to ease into each activity. For example, before bowling full games with your team, spend some time practicing a few frames at a time. Beware that any adverse response may not show up the first day after bowling. You may want to try bowling a few lines over several days before getting back into the full action. The same return to sports progression is advised for baseball.

Many studies are being done to find what works best for low back pain (LBP). There’s some evidence that any kind of exercise can help — for example, biking, walking, or swimming. Even physical activity while moving around during daily life can make a difference.

But sometimes a specific exercise-training program is needed. Research shows that muscle control may be more important than muscle strength or endurance. If the muscles don’t fire at the right time, the spine is left unstable and unprotected. If this is the case for you, a general exercise program won’t change the altered patterns of motion that cause pain.

You may have heard of a program called Core training or Pilates exercise. Improving posture, breathing, and motor control are the focus of these programs. Patients are trained to hold the spine steady or stable while moving the body, arms, and legs.

A 15-minute program four to six times a week for four to six weeks can make a difference. Movements are done slowly, smoothly, with control and without pain. A few sessions with a physical therapist (PT) may help to get you started doing the exercises properly. Studies show this works better than “usual care” with advice from the doctor or PT.

Pressure on any nerve tissue can result in numbness, tingling, pain, and/or weakness. This kind of phenomenon can occur at the site of any nerve. There are two main ways symptoms may be produced.

First, when compression or obstruction is placed on or around a nerve, signals through the spinal cord to the brain result in warning or red alert symptoms. The body is trying to let the brain (and person) know there’s a problem. So pay attention and do something about it!

Second, this same compression or obstruction can cut off the blood supply to the nerve tissue. This is called neuroischemia. If the symptoms are present all the time, it’s a static or chronic condition. In the case of NIC, certain positions improve the blood flow and reduce the symptoms.

For example, bending forward opens up the space around the spinal cord, taking pressure off the tissues in that area. Standing up straight or even arching the back into extension has the opposite effect. If the symptoms come and go based on whether your spine is flexed or extended, you may have what’s called dynamic neuroischemia.

The symptoms you’re describing are classic for a condition called neurogenic intermittent claudication (NIC). Pain, numbness, and weakness in the low back, buttocks, and legs are common with this condition. The symptoms gradually get worse as the affected person stands and walks. Sitting, lying down, or bending forward are the positions of greatest comfort.

The cause of the problem is usually spinal stenosis, a narrowing of the spinal canal where the spinal cord is located. The spinal cord ends around L2 so symptoms from this condition can also come from pressure on the spinal nerves as they exit the spinal canal.

A medical exam is best to be certain what the problem is — and the best treatment. Many older adults with spinal stenosis also have arthritic changes in the bones of the spine that can make the problem more difficult to treat. Positions and exercises that might help the stenosis can make the arthritis worse.

Antiinflammatory drugs may be of some help. If a course of conservative treatment doesn’t bring relief from symptoms, your mother may be a good candidate for surgery. A special device called the X STOP can be used to put space between the bones of the spine. This prevents the spine from extending while standing and takes the pressure off the nerve tissues.

The high cost of health care has pushed doctors to find better ways to treat common problems like chronic low back pain (CLBP). They have to be able to show the treatment used really works. This is called evidence based medicine.

The number of adults affected by CLPB is on the rise. This trend is expected to continue as a large number of Americans continue to age and experience back pain. More back surgery is being done than ever before. But there’s no proof that surgery is the best answer.

Scientists have identified five areas that can be used as a measure of success after treatment for CLBP. These include 1) pain, 2) function, 3) well-being, 4) disability, and 5) patient satisfaction.

Finding one survey tool to assess all five areas has been a problem. That’s why some doctors end up using more than one questionnaire. Recently, researchers in Spain evaluated a new tool called the CORE SET. With six questions, all five domains are assessed reliably.

If this tool is tested and found valid with English-speaking patients, it may replace all the other longer surveys.

There are many ways to measure the success of treatment for various problems and conditions. With back pain from any cause, there are two surveys used most often: the SF-36 and the Oswestry. These have to be filled out before surgery and then again after surgery to show if the patient is better, same, or worse.

There is a new survey being tested with low back pain (LBP) patients. It is patient-based meaning it looks at the patient’s pain level, function, and sense of personal well-being. It even measures patient satisfaction. Like all other measures of outcome, it must be completed before and after treatment.

The surgeon often goes by results seen on X-ray or other imaging studies. Patient-based results aren’t always the standard of measure. Talk with your surgeon if you aren’t happy with the results of your operation. You may be a good candidate for a short course of rehab or other treatment that could help.

There are a couple good books on the market that have become standards of care for many patients. The first is the Royal College of General Practitioner’s The Back Book available at www.Amazon.com. The second is Robin McKenzie’s Treat Your Own Back also available at www.Amazon.com.

Other helpful patient education materials are available at www.eorthopod.com. Click on ‘Spine’ along the left side of the web page. Go to ‘Lumbar’ and you will find several patient guides that may be of interest. Look for A Patient’s Guide to Low Back Pain and Back Care Boot Camp.

If keeping active and following the guidelines in any of these materials doesn’t improve your symptoms, you may want to seek medical advice. If the source of your painful symptoms is not a serious problem, you may benefit from one or two sessions with a physical therapist (PT). The PT can identify specific areas to work on such as posture, flexibility, or strength.

Use this episode of back pain to get started with an overall fitness plan that addresses all these areas at home and at work.

Researchers around the world are studying and comparing costs and types of treatment for back pain patients. It’s difficult to compare results of one study to another when different age groups are treated or when the treatment applied isn’t the same between studies.

So far it looks like exercise and advice to stay active have the best results. For patients with low levels of disability, advice to stay active may be all that’s needed.

Patients with greater pain or more disability may be helped more by joint mobilization or manipulation performed by a PT. The optimum number of visits or treatments with a PT has not been established yet.

More studies are needed to compare and match types of patients with best practice methods of treatment. It may be that certain age groups or conditions will respond to one treatment or a combination of treatments compared to other problems causing low back pain.

Most PTs are very willing to help patients achieve their goals physically and financially. Patients paying out-of-pocket can be given more independence with a home program and follow-up by phone or email. Present your concerns and needs when you make the initial appointment.

Your therapist will take a history and perform a physical exam much like your doctor did. Although the information gathered and the tests given are very similar, the therapist will be reviewing the results with a little different point of view.

Identifying the underlying cause or soft tissue structures that are injured helps guide the therapist’s treatment. The goal is to treat as specifically as possible. The therapist will watch for any red flags that could signal a more serious problem such as infection, tumor, or fracture.

Studies show that passive treatment with heat, cold, and massage may not be effective for many back pain patients, especially those who have chronic pain. They may feel good in the short-term but they don’t seem to have a permanent benefit. Exercise therapy combined with spinal manipulation/mobilization has the best record for improving pain and disability.

The therapist will likely give you a home program of exercises to do on your own. Instruction on posture while standing, sitting, and lying down along with guidelines for lifting will be part of your treatment time.

Studies are just beginning to trickle in with evidence to this effect. While it’s true that most people with back pain improve and recover on their own in one to two weeks, there are some who don’t get better. In these cases, earlier treatment has been shown to reduce pain and disability with fewer long-term problems.

What we don’t know is how to predict who is going to need early intervention. Researchers are trying to find out what factors make a difference in the final result. Some factors under investigation include patient age, type of treatment, presence of depression, and job satisfaction.

In a recent study from the University of Wisconsin-Madison, patients with symptoms lasting more than six months were less likely to improve with treatment. Not only that, but it took more treatments to get the same amount of pain relief and improved function compared to patients who had symptoms less than one month.

If your mother is an older adult a visit to her primary care physician may be a good idea. A medical exam for any serious causes of dizziness and/or falling is important. If there’s nothing wrong, then a short course of physical therapy can be very valuable in preventing a chronic problem and possibly preventing future injury.

You may be looking for what doctors refer to as Clinical Practice Guidelines (CPGs). There are several CPGs published on the topic of low back pain (LBP). Most of these are based on scientific evidence, not just agreed-upon opinions of several doctors.

The Agency for Health Care Policy and Research (AHCPR) publishes materials of this type. AHCPR has been renamed to Agency for Healthcare Research and Quality (AHRQ). CPG number 14: Acute Low Back Problems in Adults: Assessment and Treatment was published in 1994.

Although still in use, this document is no longer viewed as current. You can take a look at it yourself on-line at http://www.ahrq.gov/clinic/cpgarchv.htm. A patient-friendly version of these guidelines is also available on-line at http://www.chirobase.org/07Strategy/AHCPR/ahcprconsumer.html or by calling 1-800-358-9295.

Another excellent resource A Patient’s Guide to Low Back Pain is also available on line at /eorthopodV2/index.php/fuseaction/topics.detail/ID/79791a8f7dd9f446b38653cbeab9a955/TopicID/840d34b9d079dd898138d113221c56f3/area/5.

You may want to review these materials with your physician and find out what he or she would advise for your specific situation. General guidelines apply to many patients with nonspecific LBP but may not be appropriate for everyone.